The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

Disturbed Sleep Pattern related to difficulty staying asleep

Disturbed Thought Processes related to chronic insomnia

Risk for injury related to somnambulism

Risk for Impaired Gas Exchange related to sleep apnea

Answer and Explanation

The Correct Answer is C

The priority nursing diagnosis for this client should be Risk for injury related to somnambulism. Somnambulism, also known as sleepwalking, can put the client at risk for injury as they may engage in activities while not fully conscious. The client's report of falling asleep while driving and almost being involved in an accident further highlights the potential risk for injury. It is important for the nurse to address this risk and develop a plan to ensure the client's safety.

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Correct Answer is D

Explanation

The adult client is displaying regression, which is a defense mechanism where an individual reverts to an earlier stage of development in response to stress or conﬂict. In this case, the client is throwing a temper tantrum, which is a behavior typically associated with young children, because he does not get his own way. This behavior can be seen as a regression to a less mature way of coping with stress or conﬂict.

A. To determine the need for medications B. To evaluate ﬂuid volume status C. To evaluate the glomerular filtration rate D. To determine the amount of retained urine after voiding. E. To determine the extent of renal failure

Correct Answer is ["A","D"]

Explanation

A test to determine the amount of residual urine is used to measure the amount of urine that remains in the bladder after voiding. This assessment can be used for several reasons, including to determine the need for medications that can help improve bladder emptying and to evaluate the amount of retained urine after voiding. Retained urine can increase the risk of urinary tract infections and other complications. This test is not typically used to evaluate ﬂuid volume status, glomerular filtration rate, or the extent of renal failure.

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The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking care of an adult client who throws a temper tantrum because he does not get his own way. Which defense mechanism is the adult client displaying?

Correct Answer is D

Explanation

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Select all that apply.

Correct Answer is ["A","D"]

Explanation

A client is prescribed a diuretic for swelling of the lower extremities. The nurse should teach the client about the eﬀect of the medication on the client's urinary output.

The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

During a home visit, the nurse explains the procedures for preventing infection in a central venous access device to the spouse who watches while the nurse hooks the client to the medication infusion. Which role is the nurse performing at this time?

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

How would a nurse document the condition in which a client has a normal state of awareness?

The nurse instructs the client on mind-body therapies. Which mind-body therapy is used when the client pictures themselves lying on a beach with the sounds of waves, the cries of seagulls, and the warmth of the sun during periods of stress?

A nurse is conducting a lung assessment on a client suspected of having pneumonia. Which finding should the nurse report to the physician immediately?

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?